Operative Trauma Conference Ureter and Bladder Injuries Daniel Pust, MD

Ureteral Injury account for less than 1% of all genitourinary trauma penetrating trauma iatrogenic blunt (6%)

Diagnostic Work-up Microscopic Hematuria only present in % 30 % false negative rate CT scan and IVP 90 % sensitivity Intra-op Methylenblue Retrograde uretrography (post op, iatrogenic) check drain fluid for creatinine

General Operative Principles Locate ureter at the level of iliac vessels bifurcation Trace proximal and distal Avoid devascularization Resect necrotic segment

General Operative Principles Double J stent 6 or 7 Fr, 22 – 30 cm double J with Glidewire One end positioned in renal pelvis, second end positioned in bladder Spatulate ends Tension free repair

General Operative Principles 4-0 Vicryl 4-0 PDS Interrupted Place tissue (omentum) around repair JP-drains

Types of repair Primary anastomosis Ureteroneocystostomy (Psoas Hitch) Boari flap Small bowel interposition Damage control: ligate, delayed percutaneous Nephrostomy tube

DO NOT PERFORM Transureteroureterostomy Uretrostomy

Boari flap

Small Bowel Interposition

Bladder Repair 10 % of pelvic Fx are associated with bladder rupture 94% have gross hematuria Dx established by CT cystogram extraperitoneal 58 % Intraperitoneal 33 % combined 10 %

Bladder Repair Carefully evaluated bladder If injury present, open dome of the bladder in midline Inspect bladder from the inside Locate ureteral orifices and urethra

Repair extraperitoneal injuries from the inside Single layer of interrupted 2-0 or 3-0 absorbable Intraperitoneal rupture is closed with 2 layers of running absorbable suture

Foley for days Suprapubic tube is usually not indicated Always place drain Cystogram prior to Foley removal